Crisis Adrenal

Dr. Sony Wibisono dr, SpPD, K-EMD, FINASIM

School of Medicine Airlangga University
 Adrenal Failure
• Basal failure results in adrenal insufficiency
– Leads to insidious wasting disease
• Stress failure results in adrenal crisis
• Life-threatening
• Absence of glucocorticoids is most critical
 Adrenal Insufficiency
• Primary = failure of adrenal glands
• Secondary = failure of HPA axis
– Usually due to chronic exogenous glucocorticoid
administration
– pituitary failure
• Tertiary = Hypothalamic dysfunction
 Adrenal Crisis
CLINICAL PRESENTATION
• Life-threatening emergency
• May be primary or secondary
• HYPOTENSION
– Typically resistant to catecholamine and IVF resuscitation
 Adrenal Crisis
CLINICAL PRESENTATION
• Abrupt adrenal failure usually from gland
hemorrhage or thrombosis
– Anticoagulation
– DIC
– Sepsis (Waterhouse-Friderichsen syndrome)
– Usually have abdominal and flank pain
– Can resemble ruptured AAA!!!
 Adrenal Crisis
CLINICAL PRESENTATION
• Catastrophic HPA axis failure
– Head trauma
– Hemorrhage of pituitary adenoma
– Post-partum herniation (Sheehan syndrome)
– Usually neurological deficits, headaches, visual field cuts
and diabetes insipidus
 Diagnosis
• Short corticotropin stim test
– Get baseline level
– Inject 250gm cosyntropin (IV or IM)
– Measure plasma cortisol level in 60 minutes
– Excluded if basal or test level is > 525 nmol/L
• Plasma cortisol levels between 8am-9am
– Level <83 nmol/L rules IN
– Level >525 nmol/L rules OUT
 Treatment – stable patient
• Admit to internist for stim test
“Other tests of adrenal function are much too time-
consuming and cumbersome to warrant their use in
the ED”.
 Treatment – stress or rescue
• Base the dose of suppressive therapy on the severity
of the stressful even
• Use glucocorticoids only (no mineralcorticoids)
100mg bolus of IV hydrocortisone followed by
infusion of 200mg IV over next 24 hours
• Correct volume and sugar deficits with D5NS
• Dexamethasone is of no utility
Thank you 4 your attention